OneCare VermontOverview Continued

House Committeeon

Health Care

Vicki Loner RN.C, MHCDS, VP & COO 4/11/2019

onecarevt.org

onecarevt.org 2

Central Components of the Care Coordination Model

Inclusive Payment Model

2

Multi-disciplinary Care

Teams

1

Person-centeredShared Care

Plan

4

Tools & Training

3

Risk Stratification

Vision:To provide high-quality, person-centered,

community-based care coordination services in an integrated delivery system

to achieve optimal health outcomes

Patients5

Inclusive Payment Model

Patients

Community Health Teams

SASH

Designated Agencies

Primary Care

Home Health

Acute Care

Area Agencies on Aging

OneCareVT.org 3

Care Coordination Payment Model

Level 3: Patient

Activation & Lead Care

Coordination Payment

Level 2: PMPM for Team-Based Care

Coordination (Top 16% Medicaid & Medicare; Top 3% BCBS QHP)

Level 1: Community Capacity PaymentOne time annual $25,000 payment per community for project management support: community-specific

workflows; workforce readiness & capacity development; analysis of community care coordination metrics, gap analysis and remediation

• Monthly $15 PMPM to TIN of Continuum of Care Team Member

• Designated Agency 60%• Home Health 45%• Area Agency on Aging 25%• Primary Care 100%

Main Activities:• Actively participate on care team• Contribute to patient-centered

shared care plans • Participate in care team meetings,

care conferences, and transitional care planning

• One time annual $150 payment to TIN of Lead Care Coordinator

• Additional $10 PMPM to TIN of Lead Care Coordinator

Main Activities:• Activate and engage patients in care

coordination• Lead development of shared care plan,

document in Care Navigator • Populate care team in Care Navigator• Coordinate communication among care

team members• Plan & facilitate care conferences

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Shared Care Plan

onecarevt.org 5

TOM’S STORYResults from Engagement 2016-2017

Patient profile:• Patient in his 40s

• Outreach began in June 2017 and patient engaged in care coordination as of September 2017

• Conditions include: Schizophrenia, Coronary Artery Disease, and Hypertension with poor control

0123456

2016 2017

ER Visits

0123456

2016 2017

Primary Care Physician Visits

0$14K$28K$42K$56K$70K

2016 2017

Health Care Costs (Totals)

Total Health Care Costs decreased

by 60%

Primary Care Physician visits

increased

Emergency Department visits

decreased

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onecarevt.org 7

onecarevt.org 8

“My career as a family practice physician working

in Vermont spans nearly two decades. One of the

most positive changes I have seen is the creation

of OneCare. One of the key aspects of OneCare is

to reward primary care providers like me to work

with our patients to keep them healthy rather

than treating them only when they are sick. This

approach is an effort to move away from the

current fee-for-service system and move us to a

value-based system focused on improving quality

and promoting wellness by focusing on primary

care for Vermonters.”

Carrie Wulfman, MDPrimary Care Provider, Primary CareBrandon, VT

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Working to Reduce Administrative Burden

Quality Measure Alignment and Reduction

Prior Authorization Waivers for Medicaid

Skilled Nursing Facility, Telemedicine, and Home Health Waivers

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2019 Quality Measure Medicare Medicaid BCBS QHP UVMMC SF Domain

Follow-Up after Discharge from the Emergency Department for Mental Health or Alcohol or Other Drug Dependence (NQF)

x Claims

30 Day Follow-Up after discharge from the ED for Alcohol and Other Drug Dependence (HEDIS FUA)

x x x Claims

30 Day Follow-Up after Discharge from the ED for Mental Health (HEDIS FUM) x x x Claims

Risk Standardized, All Condition Readmission (ACO #8) x Claims

Adolescent Well-Care Visits (HEDIS AWC) x x x Claims

All-Cause Unplanned Admissions for Patients with Multiple Chronic Conditions (ACO#38)

x x Claims

Developmental Screening in the First Three Years of Life (NQF) x x Claims

Initiation of Alcohol and Other Drug Dependence Treatment (NQF, HEDIS IET) x x Claims

Engagement of Alcohol and Other Drug Dependence Treatment (NQF, HEDIS IET) x x Claims

Initiation & Engagement of Alcohol and Other Drug Dependence Treatment (Composite) (HEDIS IET)

x x Claims

ACO All-Cause Readmissions (HEDIS PCR) x x Claims

Follow-Up After Hospitalization for Mental Illness (7 Days) (HEDIS FUH) x x x Claims

Influenza Immunization (CMS 147v6) x Clinical

Colorectal Cancer Screening (CMS 130v5) x Clinical

Tobacco Use Assessment and Cessation Intervention (CMS 138v5) x x Clinical

Screening for Clinical Depression and Follow-Up Plan (CMS ACO 18) x x x x Clinical

Diabetes HbA1c Poor Control (>9.0%) (CMS 122v5, HEDIS) x x x Clinical

Hypertension: Controlling High Blood Pressure (ACO #28, HEDIS) x x x x Clinical

CAHPS Patient Experience x x x Survey

onecarevt.org 11

OneCare Vermont Financial Flow

Payer Fixed Health Care Cost~$843 million

(Medicaid, Medicare, BCBSVT)

Pay OneCare Monthly for:($352 million)

• $315 Million Hospital Fixed Prospective Payment Allocation (includes all services, including hospital employed primary care)

• $37 Million Health Care Reform Investments for OneCare Population Health Management

Hospital & CPR Practices• Fixed Prospective Payments• Population Health Management Payments• Care Coordination Program Payments• Value Based Incentive Fund

Pay Directly to Delivery System:(Fee for Service $528 million)

• All Providers other than Participating Hospitals including:

• FQHCs• Independent Primary Care & Specialists• Home Health & Hospice, Designated

Agencies, Skilled Nursing Facilities

Non-Hospital Attributing Practices

• Population Health Management Payments• Care Coordination Program Payments• Value Based Incentive Fund

Non-Attributing Practices• Care Coordination Program Payments• Value Based Incentive Fund

Health Care Reform (HCR) Investments~$37 million

(Medicaid, Medicare, BCBSVT, Hospitals)

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Value-Based Care SettlementAfter the year is over, there is a reconciliation between the payer and OneCare

• This can result in a payment to the providers (shared savings) or a payment back to the payer (shared losses or “risk”)

• As a protection for both parties, there are limits to the size of the reconciling payments

2019 Estimates Medicare Medicaid BCBS QHP

Spending Target $581,000,000 $211,000,000 $99,000,000

Max Effective Shared Savings or Losses Rate 5% 4% 3%

Max Shared Savings or Losses +/- $29.0M +/- $8.4M +/- $3.0M

BCBSVT based on paid amount

Appendix

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Report on Medicaid Accountable Care Organizations in Four States: Implementation and Early Impacts

"Only Vermont’s ACO demonstrated slower growth in total Medicaid expenditures...Vermont experienced the greatest number of statistically significant reductions or slower growth across expenditure categories.”

"In practice, Vermont was the only state to achieve significant coordination across payers: Vermont made significant efforts to align operational aspects of its Medicaid and commercial ACO shared savings programs with the Medicare Shared Savings Program."

15

50%

60%

70%

80%

90%

100%

$4,500 $9,500 $14,500 $19,500 $24,500

Qua

lity

Scor

e1

Cost per Beneficiary per Year

MSSP ACO Cost vs. Quality 2017 Results

◆ACOs receiving shared savings distribution

◆ACOs beat target but did not earn shared savings

◆ACOs that did not beat target

●OneCare Vermont (did not beat target)

ACOs receiving shared savings distributions

159

ACOs beat target but did not earn shared savings

125

ACOs that did not beat target 188

TOTAL 472

211 ACOs were above OCV’s cost per beneficiary and beat their targets or generated Shared Savings

Average: 83%Av

erag

e: $

10,5

77

Footnotes1 This figure is calculated internally as if all measures were performance scored rather than any pay-for-reporting; this calculation will more closely match the CMS-Calculated figure over time as CMS decreases the pay-for-reporting component (score does not include quality improvement points). 2 Genesis Healthcare ACO, LLC; SEMAC; Accountable Care Coalition of Western Georgia, LLC; AmpliPHY of Texas ACO LLC; Sandhills Accountable Care Alliance, LLC; and KCMPA-ACO, LLC are not shown on the graph due to outlier status in cost or quality.

2019 Attribution Summary by Payer

Medicare Medicaid BCBSVT Commercial

Attributable Populations • Medicare eligible• Includes those with dual

eligibility• Excludes those with Medicare

Advantage plans

• Medicaid eligible• Excludes those with dual

eligibility• Excludes those with a limited

Medicaid benefit plan (ie, Rx only)

• Qualified Health Plan only• Does not include those

enrolled in self-funded or employer-sponsored plans

Attribution Type Prospective with quarterlyretroactive removal of ineligible patients to start of performance

year

Prospective with monthly removal of ineligible patients --may return if become eligible for

Medicaid again

Prospective with monthly removal of ineligible patients –

may return if become eligible for BCBSVT again

Look Back Period 2 Years7/1/2016 - 6/30/2018

2.5 Years1/1/2016 - 6/30/2018

2 YearsCalendar Year 2017-2018

Patient Attributed to Provider with…

Highest weighted allowed charges* for QEM+ services during the lookback period (Year 2 weighted twice as

heavily)

Highest weighted allowed amount* for QEM+ services

during lookback period (2nd half weighted twice as heavily)

• If plan requires PCP selection, member attributed to PCP; otherwise highest number of QEM+ services during lookback period

Attribution to Advanced Practice Providers (APP)

Yes Yes Yes

Patient visit required during look back to be attributed

Yes Yes No

Primary care visit with DOCTOR required during lookback to be attributed

No No No

Eligibility/Plan Categories ESRD, Aged/Disabled ABD (Child and Adult), Consolidated Adult, Consolidated

Child; No newborns

Platinum, Gold, Silver, Bronze, Catastrophic

* Allowed Amount/Charges: The amount paid by the insurer plus the amount the patient is responsible for paying (deductible, coinsurance, etc.)+ QEM Services: Qualified Evaluation and Management services

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OneCare Vermont Tax Status

OneCare is not operated to make profits. We are provider led and operate in alignment with the non-profit missions of our founders and the many providers who participate. OneCare budgets to break even and surpluses are either added to reserves that are required by regulators or distributed to provider participants who have met the standards for delivering high quality care.

Although we believe that OneCare could fulfill the tax exempt non-profit requirements, as a strong provider led LLC, it is not eligible for Vermont non-profit status. Unique restrictions in Vermont law do not allow non-profits to have more than 49% of their Board financially interested. ACO regulations require that 75% of the Board be provider representatives, and providers can receive savings and funding from the ACO.

onecarevt.org 18

Looking Ahead in 2019

Comprehensive Payment Reform Expansion for Independent Primary Care• Expanding sites from 3 to 9• Further reducing prior authorization requirements for Medicaid

Developmental and Legal Collaboration for Everyone (DULCE) Pilots• Parent Child Center Partnership at 3 new sites in Franklin, Windsor, Chittenden County

Community Led Innovation Pilots

St. Johnsbury Accountable Community for Health• Geographic focus to further invest in prevention interventions and expand care model to

new populations

Specialty Payment Investments to Improve Access and Strengthen Integration between primary and specialty care

Expanding Benefit Enhancement Waivers (Home Health, SNF, and Telemedicine)

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Medicaid Funds Flow – Example Hospital

Medicaid

OneCare Vermont

Fixed Prospective Payment:$900,500

Population Health Management:

$17,800

Care Coordination Program:$13,200

Pay Hospital Monthly for:• Fixed Prospective Payment (covers all services including hospital primary care)

• OneCare Population Health Management Investments

$931,500

Separate Annual Payments for:

• Value Based Incentive Fund

• Shared Savings

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OneCare Vermont Board of ManagersSeat Individual

Community Hospital-Critical Access Dan Bennett – CEO Gifford Health Systems

Community Hospital - PPS Jill Berry-Bowen - CEO Northwestern Vermont Health Care

UVM Health Network John Brumsted, MD - Chief Executive Officer

Consumer (Medicare) Betsy Davis - Retired Home Health Executive

At-Large (Risk Strategy Committee) Tom Dee - CEO Southwestern Vermont Medical Center

At-Large Steve Gordon - CEO Brattleboro Memorial Hospital

Independent Primary Care Physician Joseph Haddock, MD- Thomas Chittenden Health Care

Mental Health/Designated Agency Tomasz Jankowksi - CEO Northeast Kingdom Human Services

UVM Health Network Todd Keating - Chief Financial Officer

Dartmouth-Hitchcock Health Sally Kraft, MD – Vice President of Population Health

Dartmouth-Hitchcock Health Steve LeBlanc - Executive Vice President

UVM Health Network Steve Leffler, MD - Chief Population Health Officer

Consumer (Medicaid) Sierra Lowell – Nursing Student

Skilled Nursing Facility Judy Morton - Regional Executive Director Genesis

FQHC Pamela Parsons - Executive Director Northern Tier Center for Health(NOTCH)

Dartmouth-Hitchcock Health Joe Perras, MD - CEO Mt. Ascutney Hospital

Home Health Judy Petersen - CEO VNA of Chittenden/Grande Isle Counties

Independent Primary Care Physician Toby Sadkin, MD - Primary Care Health Partners

Consumer (Commercial) John Sayles - CEO Vermont Foodbank

FQHC Grant Whitmer – Executive Director of Community Health Centers of the Rutland Region

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Network ParticipationHealth Service Area Home Hospital 2017 2018 2019Burlington UVM Medical Center Medicaid All Risk Programs All Risk ProgramsBerlin Central Vermont Medical Center Medicaid All Risk Programs All Risk ProgramsMiddlebury Porter Medical Center Medicaid All Risk Programs All Risk ProgramsSt. Albans Northwestern Medical Center Medicaid All Risk Programs All Risk ProgramsBrattleboro Brattleboro Memorial Hospital All Risk Programs All Risk ProgramsSpringfield Springfield Hospital All Risk Programs All Risk ProgramsLebanon Dartmouth Hospital and Clinic Medicaid and BCBSVT Medicaid and BCBSVTBennington Southwestern VT Medical Center Medicaid All Risk ProgramsWindsor Mt Ascutney Hospital Medicaid All Risk ProgramsNewport North Country Hospital Medicaid MedicaidRutland Rutland Regional MedicaidSt. Johnsbury Northeastern Regional Hospital MedicaidRandolph Gifford Medical Center MedicaidMorrisville Copley HospitalTownshend Grace Cottage

Green: Advancing participation from prior year

Key Additions & Changes:• Bennington and Windsor advancing to participation in all risk programs• Randolph, Rutland, and St. Johnsbury participating in Medicaid for the first time• Newport maintaining Medicaid-only participation due to a recent leadership change• Expansion includes six FQHCs

OneCareVT.org 22

Multiple Payer Programs (Medicare, Medicaid, Commercial) Medicaid Only

HSA Bennington Berlin Brattleboro Burlington Lebanon Middlebury St. Albans Springfield Windsor Newport Randolph Rutland St. Johnsbury

Hospital Southwest-ern VT

Medical Center

Central Vermont Medical Center

Brattleboro Memorial Hospital

UVMMedical Center

DHMC PorterMedical Center

Northwest-ern Medical

Center

SpringfieldHospital

Mt. AscutneyHospital

North Country Hospital

Gifford Medical Center

Rutland Regional

Northeastern Regional

FQHC CHCB**** NOTCH SMCS Gifford Health Care

CHCRR Northern Counties

Health Care

Indep. Primary Care

5 Organizations

1 Organization

11 Organizations

2 Organizations

2 Organizations

1 Organization

1 Organization

Indep.Specialist

4 Organizations

3Organizations

10 Organizations

1 Organization

3 Organizations

3 Organizations

1 Organization

Home Health

VNA & Hospice of

the Southwest Region**; Bayada*

Central VT Home Health

& Hospice

VNA of VT and NH;Bayada*

UVM Health Network

Home Health & Hospice;

Bayada*

VNA of VT and NH

Addison County Home

Health & Hospice

Franklin County Home

Health Agency

VNA of VT and NH

VNA of VT and NH

Orleans Essex VNA &

Hospice

VNA of VT and NH

VNA and Hospice of

the SouthwestRegion**

Lamoille Home Health

Agency (Hardwick);Caledonia

Home Health & Hospice***

SNFs 2 SNFs 3 SNFs 3 SNFs 3 SNFs 1 SNF 3 SNFs 1 SNF 1 SNF 2 SNFs 3 SNFs 1 SNF

DAs United Counseling Service of

Bennington County

Washington County Mental Health

Health Care and

Rehabilitation Services of

Southeastern Vermont

Howard Center

Health Care and

Rehabilitation Services of

Southeastern Vermont

CounselingService of Addison County

Northwestern Counseling &

Support Services

Health Care and

Rehabilitation Services of

Southeastern Vermont

Health Care and

Rehabilitation Services of

Southeastern Vermont

Northeast KingdomHuman Services

Clara Martin Center

Rutland Mental Health

Services

Northeast Kingdom Human Services

Other 1 Spec Svc. Agency

1 Naturopath1 Spec. Svc.

Agency

1 Other(Brattleboro

Retreat)

3 Naturopath1 Spec. Svc.

Agencies

1 Other (DH Clinic)

1 Naturopath 1 Spec. Svc. Agency

1 Naturopath

2019 OneCare ACO Community of Providers

OneCare has Collaborator Agreements with AAAs across Vermont as well as with the SASH Program*Bayada serves the entire state of Vermont, these are the communities where there are main offices** VNA & Hospice of the Southwest Region services both the Bennington and Rutland HSAs*** Part of Northern Counties Health Care**** CHCB participates in Medicare and Medicaid only

Updated 01-30-19